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Complete before commencing any maintenance, repair or inspection on isolated equipment
PAGE 1 OF 2
Energy Source Identification
List every energy source. Document the isolation point, method, lock number and tag number for each.
| # | Energy Type | Isolation Point | Isolation Method | Lock # | Tag # |
|---|---|---|---|---|---|
| 1 | |||||
| 2 | |||||
| 3 | |||||
| 4 | |||||
| 5 | |||||
| 6 | |||||
| 7 | |||||
| 8 |
Pre-Isolation Checklist
Mark each item: P = Pass | F = Fail | N/A = Not applicable.
| # | Check | P | F | N/A | Notes / Action |
|---|---|---|---|---|---|
| 1 | All energy sources identified | ||||
| 2 | Affected personnel notified | ||||
| 3 | Equipment shut down in normal sequence | ||||
| 4 | All isolation points locked and tagged | ||||
| 5 | Stored/residual energy dissipated or blocked | ||||
| 6 | Zero energy verification completed (try test) | ||||
| 7 | Isolation register updated | ||||
| 8 | LOTO signage in place |
Re-Energisation Checklist
Complete all items before removing locks and returning equipment to service.
| # | Check | P | F | N/A | Notes / Action |
|---|---|---|---|---|---|
| 1 | All tools and materials removed from equipment | ||||
| 2 | All guards and covers replaced | ||||
| 3 | All personnel clear of equipment | ||||
| 4 | Locks and tags removed by authorised person only | ||||
| 5 | Affected personnel notified of re-energisation | ||||
| 6 | Equipment restarted and tested |
Declaration
I declare that all energy sources have been identified, isolated, locked and tagged in accordance with the organisation's isolation procedure. Zero energy verification has been completed. All personnel have been notified. This checklist has been completed accurately and to the best of my knowledge.